International Journal of Research in Medical Sciences
Vashishta S et al. Int J Res Med Sci. 2017 Mar;5(3):1090-1094
www.msjonline.org
Original Research Article
pISSN 2320-6071 | eISSN 2320-6012
DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20170667
Impact of menstrual cycle phases on C-reactive protein concentrations
Shilpi Vashishta1*, Sushila Gahlot1, Anita Singh2, Rajni Goyal1
1
Department of Physiology, 2Department of Gynaecology, Gian Sagar Medical College, Rajpura, Patiala, Punjab, India
Received: 07 January 2017
Revised: 10 January 2017
Accepted: 08 February 2017
*Correspondence:
Dr. Shilpi Vashishta,
E-mail: [email protected]
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: C-reactive protein (CRP) is one of the most commonly employed indicator of acute phase reaction and
predictors of cardiovascular disease in healthy women; although, only a sparse information on its variations during a
regular menstrual cycle is currently available. Our objective was to see whether CRP levels are affected during
different phases of menstrual cycle.
Methods: Females aged 15-45 years with regular menstrual cycle in terms of length, flow and variation from cycle to
cycle were followed for one menstrual cycle. Serum levels of C-reactive protein were measured in the Follicular (10th
day) and in the Luteal (22nd day) phase of the menstrual cycle.
Results: C-reactive protein levels were observed to vary in response to the phases of menstrual cycle. The
concentrations of C-reactive protein levels tend to be highest during the Follicular phase and it declined significantly
in the Luteal phase.
Conclusions: Identifying the fluctuations in C-reactive protein levels during the menstrual cycle is essential as there
may be clinical implication of the suitable timing of assessment while framing and concluding studies in women of
reproductive age.
Keywords: C-reactive protein, Menstrual cycle, Predictor
INTRODUCTION
CRP is a established independent predictor of future
cardiovascular disease.1 CRP is an acute phase reactant
produced in liver in response to interleukin-6, interleukin1, and tumour necrosis factor α. It has a molecular weight
of approximately 11,800 Da.2 Besides liver, coronaryartery smooth-muscle cells, inflamed kidneys, human
neurons, alveolar macrophages, and adipose tissue also
produce CRP.3 CRP is normally present in very small
amount in serum and it levels rises quickly and
significantly in various infectious and inflammatory
conditions. It is an indicator for low level of persistent
inflammation.4 Although CRP was initially believed to be
only an indicator of vascular inflammation, latest studies
show that it also actively participates in atherogenesis by
increasing the formation of plaque on interior walls of
blood vessel, decreasing the vessel ability to heal itself,
causing proliferation of immune cells that help to create
blockage on the inside of a blood vessel, reducing the
vessels ability to create new healthy cells to counteract
the injury.5,6 In addition khreiss et al have proposed that
loss of the pentameric symmetry of CRP can bring about
an altered or monomeric CRP, which might be the
significant CRP promoter of the pro-inflammatory
reaction in the coronary arteries.7
CRP is noticeable in the early stages of plaque
development and is supposed to be involved during the
atherogenic progression.8 In healthy women, raised levels
of CRP is one of the most significant predictor of
cardiovascular disease. A latest investigation from the
Women’s Health Study reported that CRP increases
prognostic value beyond that identified by standard lipid
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Vashishta S et al. Int J Res Med Sci. 2017 Mar;5(3):1090-1094
estimations, even after adjusting for age, obesity,
smoking, blood pressure and diabetes mellitus.9 Principal
female sex hormone estrogen, apart from being important
in reproduction also plays an important role in regulating
inflammation. Estrogen is mainly synthesized by ovaries,
and then it is released in the blood circulation where it
plays a major anti-inflammatory role by generating
vasodilator substance nitric oxide, decreasing white blood
cell and tumor necrosis factor-α (a pro-inflammatory
cytokine) recruitment,10 searching and destroying free
radicals and hence increasing the existence of the cell.10,11
Studies of the effect of exogeneous estrogen on CRP
levels have shown consistent results. Intake of oral
contraceptive and orally adminstered hormone
replacement therapy constantly increase CRP, whether
the preparation incorporates estrogen and progesterone or
estrogen alone.12,13 Though, dosage and delivery means
appear to intervene exogenous estrogen’s impact on
levels of CRP.14 While the outcome of some studies
exploring the effects of endogenous hormones on CRP
concentrations seems to be not in agreement with the
above patterns. As such, impact of the menstrual cycle
related hormones changes in various phases across the
normal menstrual cycle on the concentrations of CRP
needs exploration. Hence this study was proposed.
METHODS
The study was accomplished on 111 normal healthy and
regularly menstruating female subjects selected from the
Gian Sagar Medical College and Hospitals, Rajpura.
Permission from the institutional ethical committee and
an informed written consent from all the subjects were
obtained. One menstrual cycle of each subject was
included in the analysis.
Inclusion criteria
The International consensus conference proposed terms
for the most important features of menstrual bleeding was
followed. Females aged 15-45 years having menstrual
cycle length of 24-38 days with flow of 4-8 days and
variation of 0-20 days from cycle to cycle were
considered as regularly menstruating women.15
Exclusion criteria







Women using oral contraceptives during the last 3
months.
Current use of supplements or prescription
medications.
Pregnancy or breastfeeding in the past 6 months.
Diagnosis of polycystic ovary syndrome.
Recent history of infections or diagnosis of chronic
medical conditions.
Having autoimmune disease or thyroid disorder.
Having a history of coronary vascular disease.
Measures
After recording the detailed menstrual history like age at
menarche, length and flow of the cycle and variation
from cycle to cycle, anthropometric measurements like
weight, height, body mass index (BMI) were recorded in
Kg/m2 . Venous blood samples from each participant
were collected twice during the menstrual cycle. The first
sampling was scheduled at follicular phase (10th day of
the menstrual cycle) and the second was scheduled at
luteal phase (22nd day of the menstrual cycle) for
estimating CRP concentrations. Five ml of fasting blood
sample were drawn from the antecubital vein of each
subject after 9-12 hrs of fasting during the follicular
phase (on 10th day of the cycle) and luteal phase (on 22nd
day) of the menstrual cycle under aseptic conditions.
Serum concentration of C-reactive protein (CRP) was
measured using enzymatic kits by Turbilatex method
with high sensitivity & specifity.16
Statisitical analysis
The data collected in the study were entered in Microsoft
excel worksheet and was subjected to statistical analysis
using the Student paired t test by Microsoft excel
software data analysis tool. The significance level was
considered at p <0.05.
RESULTS
Table 1 Represents the demographic data for population
of 111 study participants who had cycle length between
24 days and 38 days(mean SD, 29.55 2.71), flow between
4 and 8 days(mean SD, 4.88 1.14), variation from cycle
to cycle between 0 and 20 days(mean SD, 4.27 3.22). The
mean age of the participants was 26±8 years and the
mean body mass index(BMI) was 23.07± 3.81 kg/m2 at
the screening visit.
Table 1: Demographic data of regularly menstruating
women.
Age(yrs)
Height(m)
Weight(kg)
BMI(Kg/m2)
Waist/ hip ratio
Length of menstrual cycle(days)
Flow (days)
Variation from cycle to cycle(days)
Mean
26
1.6
59.3
23.07
0.86
29.55
4.88
4.27
SD
8
0.065
10.71
3.81
0.06
2.71
1.142
3.22
SD: Standard Deviation.
Table 2 presents the concentrations of CRP (Mean±SD)
during the follicular and luteal phases of the menstrual
cycle. The luteal phase measurement of CRP was
significantly lower (P≤0.00004) compared with that
during the follicular phase.
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Table 2: Serum concentration of CRP during the
follicular and luteal phase of the menstrual cycle in
regularly menstruating women.
Parameter
CRP(mg/L)
Mean
SD
Follicular
phase
Luteal
phase
1.88
1.49
1.54
1.30
P value
<0.00004*
CRP: C-Reactive Protein, SD: Standard Deviation, *significant
(P <0.05)
DISCUSSION
Very scarce literature is available to show the variations
in CRP levels during normal menstrual cycle that too
with a fewer number of subjects. Also, the present study
included regularly menstruating women based on all the
three criteria of the normal menstrual cycle i.e. the length
and flow days of menstrual cycle and variation in days
from cycle to cycle which to the best of our knowledge
has not been done in whatever small number of studies
done so far.
Additionally the exclusion criteria of the study strengthen
the ability to draw conclusion, having reduced the
potential for bias from known risk factors for
inflammation and hormonal abnormalities. The aim of the
present study was to find out the fluctuations in the
inflammatory predictor C- reactive protein concentrations
during the follicular and luteal phases of menstrual cycle.
A significant raised mean CRP levels in follicular
(1.88±1.49 mg/L) was observed compared to luteal phase
(1.54±1.30mg/L) in Regularly menstruating women
(p=0.0004). Similar observations were found by Blum et
al, Gursoy AY et al and Wander K et al, Blum et al,
reported that CRP concentrations changed significantly
during the menstrual cycle.14,17,18 The concentrations were
highest in the early follicular phase and inversely
correlated to estradiol concentrations.
Gursoy AY et al. observed similar results. CRP values
were significantly higher in the early follicular phase in
contrast to luteal phase (1.8 mg/L vs. 0.7 mg/L
respectively).18 He noticed that Estrogen levels were
inversely correlated with CRP levels hence low levels of
estrogen during early follicular phase can be underlying
physiology related with relatively high levels of CRP
during follicular phase. Further Gursoy did not find any
correlation between progesterone levels and CRP.
Wander K et al observed that progesterone increases
CRP, estrogen decreases CRP, and menstruation may
increase CRP.14 He observed a ten-fold increase in
estrogen was associated with a 29% decrease in CRP, a
ten-fold increase in progesterone was associated with a
23% increase in CRP, and menses was associated with a
17% increase in CRP while no association between
ovulation and CRP was found. Further he reported that
the negative association between estrogen and CRP is
stronger in the follicular phase, while the positive
association between progesterone and CRP is limited to
the luteal phase. In contrast to our study findings,
increased CRP has been observed by Gaskins AJ et al,
Jilma B et al in luteal phase of menstrual cycle in
regularly menstruating women, while Wunder K et al,
Saxena AR et al did not find any significant differences
in CRP concentrations during a menstrual cycle.19-22
Gaskins AJ et al found in regularly menstruating women
that CRP levels varied significantly across the cycle.19
CRP tends to be highest during menses, decreased during
the follicular phase, was lowest on the expected day of
ovulation, and increased in the luteal phase. He also
reported that CRP was significantly inversely associated
with endogenous estradiol and positively associated with
luteal progesterone. Moreover, a 10-fold increase in
estradiol was associated with a 24.3% decrease in CRP
and a 10-fold increase in luteal progesterone was
associated with a 19.4% increase in CRP. Jilma B et al in
eighteen healthy regularly menstruating premenopausal
women found a CRP increase of 44% at midcycle
(ovulation) and 31% in the luteal phase in comparison to
follicular phase levels.20
This was significant correlated to the relative rise in
progesterone levels during midcycle and the luteal phase.
Others like Wunder et al found small non- significant
differences in CRP concentrations between the follicular,
ovulatory and luteal phase of the menstrual cycle in 36
healthy, young, normo-androgenic women, having a
normal body mass index.21-22 Similarly Saxena AR et al
also observed a non-significant reduction in CRP levels
from follicular to luteal phase of menstrual cycle. The
differences between the results of Gaskins AJ et al, Jilma
et al, Wunder et al, Saxena AR et al and the present study
can most likely be explained by the differences in the
assay methodologies used for the determination of
CRP.19-22 Further Gaskins AJ et al findings reveal that
during the menses (early follicular phase) largest number
of women were at moderate-to-elevated risk of
cardiovascular disease (hs-CRP, >1 mg/L) while the
small number of women were at cardiovascular risk on
the ovulation day.19
He also noticed that except in the midluteal phase, every
clinic visit i.e. on mid-follicular, late- follicular, LH/FSH
surge day, and early and late luteal phase had
significantly fewer number of women with high-tomoderate risk of cardiovascular disease when compared
with the menses day visit. The reason for the difference
in the present findings by the results of Gaskins AJ et al
may possibly that our study time points were limited to
two specific times in the menstrual cycle, late- follicular
and mid-luteal phase which may not coincide their
timepoint in the cycle.19 These results were interpreted as
the effect of estrogen. Estrogen receptors are highly
expressed in endothelial and vascular smooth muscle
cells throughout the human body.23 Estrogen has a major
anti-inflammatory role as postulated by underlying
mechanisms:
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




Estrogen reduces levels of tumor necrosis factoralpha, a major pro-inflammatory cyctokine 10
resulting in the reduced formation and liberation of
chemokines such as interleukin-8 and platelet
activating factor along with the down regulating
adhesion molecules like intercellular adhesion
molecule 1 and E-selectin, which leads to decreased
recruitment of leukocytes.11
Estrogen can act as an antiapoptotic agent on various
cell types including endothelial cells by inhibiting
the liberation of cytochrome c from the
mitochondria, thus decreasing ensuing vascular
inflammation.24
While there are conflicting results for progesterone:
Progesterone can act as pro-inflammatory by
promoting the chemo-tactic activity of neutrophils
and increase production of some of the inflammatory
mediators like Interleukin-6 and leukemia inhibiting
factor (LIF) through monocytes.25
Progesterone can act as anti-inflammatory by
decreasing natural killer cell activity, macrophage
Tumor necrosis factor, and nitric oxide synthase
formation and inhibits the T-cell development and
activity.26
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CONCLUSION
This explains that the women with Regular menstrual
cycle have higher CRP levels in the follicular phase
where the estrogen levels are relatively low compared to
luteal phase. Hence menstrual cycle phase must be taken
into consideration by the clinicians and physicians while
interpreting a woman’s CRP measurement. While the
best time to measure CRP during a woman’s cycle has
yet to be established, measurements should be made at
the same time each month for consistent comparisons.
Application of standardized timing of CRP investigation
in reproductive-aged women would enhance the proper
interpretation in future studies as well as in clinical
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ACKNOWLEDGEMENTS
Authors would like to thank all the volunteers who
participated in the study. We acknowledge all the
Biochemistry staff members of Gian Sagar Medical
College and Hospital for helping in the biochemical
measurement.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Vashishta S, Gahlot S, Singh A,
Goyal R. Impact of menstrual cycle phases on Creactive protein concentrations. Int J Res Med Sci
2017;5:1090-4.
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